Page 9 - Enrollment Guide Non Core
P. 9
MotoMart
Schedule of Benefits
Base Plan Plus Plan
Inpatient Beneits
First day in hospital $300 per day $400 per day
Second day in hospital $300 per day $400 per day
Third day in hospital $300 per day $400 per day
Daily hospital room beneit $100 per day (days 4-60) $200 per day (days 4-60)
Inpatient surgery (lat beneit payment) Not included $500
Outpatient surgery (lat beneit payment) Not included $250
Mental illness (organic only) Covered Covered
Physician ofice visit (per day beneit) Not included $25 per visit, 2 visits per person
(max 4 per family) per year
Emergency room Not included $150 per visit, 2 visits per
person (max 4 per family) per
year, illness and accident
Critical Illness
Critical illness lump sum Not included $5,000 upon diagnosis
Preventive Services Coverage
In-network preventive services Covered at 100% Covered at 100%
No deductible No deductible
Per ACA guidelines Per ACA guidelines
Out-of-network preventive services Not covered Not covered
Telemedicine
Telemedicine program Covered at 100% Covered at 100%
Unlimited consultations Unlimited consultations
No copay No copay
Prescription Drugs Member Cost Member Cost
Tier 1 $10 $10
Tier 2 $20 $20
Tier 3 $40 $40
Weekly Employee Paid Premium * Ages 18-69 Ages 70+ Ages 18-69 Ages 70+
Employee only $7.71 $20.35 $15.30 $56.80
Employee + spouse $16.34 $28.82 $28.46 $70.40
Employee + 1 child $17.47 $42.84 $34.47 $116.40
Employee + children $24.25 $49.44 $45.21 $127.83
Employee + family $30.71 $55.90 $51.67 $134.29
Medical Treatment
If you are sick, injured, or need treatment, the plan provides cash reimbursement for certain services as outlined in the above
schedule of beneits. For covered non-preventive care treatment, you will have to pay for the services out-of-pocket and
ile a claim through Bay Bridge to obtain reimbursement as outlined in the above schedule of beneits. Please note beneit
reimbursement levels vary based on whether you select base plan or 2, and not all services are covered for reimbursement.
Additionally, you will have access to a telemedicine program and a prescription discount plan which is described later in this
booklet.
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Schedule of Benefits
Base Plan Plus Plan
Inpatient Beneits
First day in hospital $300 per day $400 per day
Second day in hospital $300 per day $400 per day
Third day in hospital $300 per day $400 per day
Daily hospital room beneit $100 per day (days 4-60) $200 per day (days 4-60)
Inpatient surgery (lat beneit payment) Not included $500
Outpatient surgery (lat beneit payment) Not included $250
Mental illness (organic only) Covered Covered
Physician ofice visit (per day beneit) Not included $25 per visit, 2 visits per person
(max 4 per family) per year
Emergency room Not included $150 per visit, 2 visits per
person (max 4 per family) per
year, illness and accident
Critical Illness
Critical illness lump sum Not included $5,000 upon diagnosis
Preventive Services Coverage
In-network preventive services Covered at 100% Covered at 100%
No deductible No deductible
Per ACA guidelines Per ACA guidelines
Out-of-network preventive services Not covered Not covered
Telemedicine
Telemedicine program Covered at 100% Covered at 100%
Unlimited consultations Unlimited consultations
No copay No copay
Prescription Drugs Member Cost Member Cost
Tier 1 $10 $10
Tier 2 $20 $20
Tier 3 $40 $40
Weekly Employee Paid Premium * Ages 18-69 Ages 70+ Ages 18-69 Ages 70+
Employee only $7.71 $20.35 $15.30 $56.80
Employee + spouse $16.34 $28.82 $28.46 $70.40
Employee + 1 child $17.47 $42.84 $34.47 $116.40
Employee + children $24.25 $49.44 $45.21 $127.83
Employee + family $30.71 $55.90 $51.67 $134.29
Medical Treatment
If you are sick, injured, or need treatment, the plan provides cash reimbursement for certain services as outlined in the above
schedule of beneits. For covered non-preventive care treatment, you will have to pay for the services out-of-pocket and
ile a claim through Bay Bridge to obtain reimbursement as outlined in the above schedule of beneits. Please note beneit
reimbursement levels vary based on whether you select base plan or 2, and not all services are covered for reimbursement.
Additionally, you will have access to a telemedicine program and a prescription discount plan which is described later in this
booklet.
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